Automation and adaptation: Nurses' problem-solving behavior following the implementation of bar coded medication administration technology

Factors Influencing Medication Administration Outcomes Among New Graduate Nurses Using Bar Code-Assisted Medication Administration

Paramount to patient safety is the ability for nurses to make clinical decisions free from human error. Yet, the dynamic clinical environment in which nurses work is characterized by uncertainty, urgency, and high consequence, necessitating that nurses make quick and critical decisions. The aim of this study was to examine the influence of human and environmental factors on the decision to administer among new graduate nurses in response to alert generation during bar code-assisted medication administration. The design for this study was a descriptive, longitudinal, observational cohort design using EHR audit log and administrative data. The study was set at a large, urban medical center in the United States and included 132 new graduate nurses who worked on adult, inpatient units. Research variables included human and environmental factors. Data analysis included descriptive and inferential analyses. This study found that participants continued with administration of a medication in 90.75% of alert encounters. When considering the response to an alert, residency cohort, alert category, and previous exposure variables were associated with the decision to proceed with administration. It is important to continue to study factors that influence nurses' decision-making, particularly during the process of medication administration, to improve patient safety and outcomes.

Describing Medication Administration and Alert Patterns Experienced by New Graduate Nurses During the First Year of Practice

The aim of this study was to describe medication administration and alert patterns among a cohort of new graduate nurses over the first year of practice. Medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. To better understand nursing workflow and documentation workload in today's clinical environment, it is important to understand patterns of medication administration and alert generation during barcode-assisted medication administration. Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. Set in a large, urban medical center in the United States, the study sample included 132 new graduate nurses who worked on adult, inpatient units and administered medication using barcode-assisted medication administration. Data were collected through electronic health record and administration sources. New graduate nurses in the sample experienced a total of 587 879 alert and medication administration encounters, administering 772 unique medications to 17 388 unique patients. Nurses experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. In addition to high volume of medication administration, new graduate nurses administer many different types of medications and are exposed to numerous alerts while using barcode-assisted medication administration.

Analysis of Publications on Health Information Management Using the Science Mapping Method: A Holistic Perspective

OBJECTIVE

In the age of digital transformation, there is a need for a sustainable information management vision in health. Understanding the accumulation of health information management (HIM) knowledge from the past to the present and building a new vision to meet this need reveals the importance of understanding the available scientific knowledge. With this research, it is aimed to examine the scientific documents of the last 40 years of HIM literature with a holistic approach using science mapping techniques and to guide future research.

METHODS

This study used a bibliometric analysis method for science mapping. Co-citation and co-occurrence document analyses were performed on 630 academic publications selected from the Web of Science core collection (WoSCC) database using the keyword "Health Information Management" and inclusion criteria. The analyses were performed using the R-based software Bibliometrix (Version 4.0; K-Synth Srl), Python (Version 3.12.1; The Python Software Foundation), and Microsoft® Excel® 2016.

RESULTS

Co-occurrence analyses revealed the themes of personal health records, clinical coding and data quality, and health information management. The HIM theme consisted of five subthemes: "electronic records", "medical informatics", "e-health and telemedicine", "health education and awareness", and "health information systems (HISs)". As a result of the co-citation analysis, the prominent themes were technology acceptance, standardized clinical coding, the success of HISs, types of electronic records, people with HIM, health informatics used by consumers, e-health, e-mobile health technologies, and countries' frameworks and standards for HISs.

CONCLUSIONS

This comprehensive bibliometric study shows that structured information can be helpful in understanding research trends in HIM. This study identified critical issues in HIM, identified meaningful themes, and explained the topic from a holistic perspective for all health system actors and stakeholders who want to work in the field of HIM.

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses

OBJECTIVES

(1) Characterize persistent hazards and inefficiencies in inpatient medication administration; (2) Explore cognitive attributes of medication administration tasks; and (3) Discuss strategies to reduce medication administration technology-related hazards.

MATERIALS AND METHODS

Interviews were conducted with 32 nurses practicing at 2 urban, eastern and western US health systems. Qualitative analysis using inductive and deductive coding included consensus discussion, iterative review, and coding structure revision. We abstracted hazards and inefficiencies through the lens of risks to patient safety and the cognitive perception-action cycle (PAC).

RESULTS

Persistent safety hazards and inefficiencies related to MAT organized around the PAC cycle included: (1) Compatibility constraints create information silos; (2) Missing action cues; (3) Intermittent communication flow between safety monitoring systems and nurses; (4) Occlusion of important alerts by other, less helpful alerts; (5) Dispersed information: Information required for tasks is not collocated; (6) Inconsistent data organization: Mismatch of the display and the user's mental model; (7) Hidden medication administration technologies (MAT) limitations: Inaccurate beliefs about MAT functionality contribute to overreliance on the technology; (8) Software rigidity causes workarounds; (9) Cumbersome dependencies between technology and the physical environment; and (10) Technology breakdowns require adaptive actions.

DISCUSSION

Errors might persist in medication administration despite successful Bar Code Medication Administration and Electronic Medication Administration Record deployment for reducing errors. Opportunities to improve MAT require a deeper understanding of high-level reasoning in medication administration, including control over the information space, collaboration tools, and decision support.

CONCLUSION

Future medication administration technology should consider a deeper understanding of nursing knowledge work for medication administration.

Barriers and Enablers of Second-Order Problem-Solving Behavior: How Nurses Can Break Away From the Workaround Culture

BACKGROUND AND OBJECTIVES

Nurses are challenged by numerous day-to-day unexpected problems due to poorly performing work systems that hinder patient care. These operational failures persist in hospitals, partly because nurses tend to prefer quick fixes or workarounds over real improvements that prevent recurrence. The aim of this review is to shed light on the barriers to and enablers of nurses' second-order problem-solving behavior and their consequences, so that hospitals can learn from failure and improve organizational outcomes.

METHODS

We conducted a systematic review, with quantitative, qualitative, and mixed-method articles, searching 6 databases (PubMed, Embase, Web of Science, CINAHL, and Google Scholar) following the Preferred Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Quality assessment for inclusion was performed by 2 independent authors using the Mixed Methods Appraisal Tool (MMAT). A descriptive synthesis was used for analysis.

RESULTS

This study reveals the barriers and enablers for second-order problem-solving behavior, and synthesizes improvement proposals within 3 perspectives, namely the "empowerment" perspective, the "process improvement" perspective, and the "time" perspective. Furthermore, we found that limited attention is given to the patient's perspective, and the existence of a no-action behavior.

CONCLUSION

Although operational failures have several important consequences for hospital staff and organizations, there has been hardly any research into the barriers and enablers that initiate second-order problem-solving behavior; stemming this nursing behavior has thus rarely appeared as a suggestion for improvement.

Exploring how caregivers for people living with dementia use strategies to overcome work system constraints

Informal caregivers for persons living with dementia (PLWD) require interventions that incorporate caregiving context. We used the Patient Work System model to characterize caregiving context by identifying work system constraints experienced by caregivers during dementia care events (e.g., managing behavioral symptoms of dementia) and strategies used to overcome constraints. We conducted twenty semi-structured interviews with caregivers. We performed upward abstraction and strategy mapping and identified seven work system constraints and eight strategies used to overcome constraints across three care events. We found that strategies used by caregivers either directly modified a constraint or emphasized other positive work system components to overcome a constraint. For example a caregiver modified their bathroom to support the PLWD in bathing themselves properly and safely. These findings provide an understanding of how real-world context influences how caregivers deliver dementia care and the design and implementation of systems that support dementia caregivers.

Identifying Electronic Medication Administration Record (eMAR) Usability Issues from Patient Safety Event Reports

BACKGROUND

Improving our understanding of the association between medication errors and health information technology (health IT) usability has the potential to reduce errors and improve patient safety. This study used patient safety event reports (PSEs) to investigate the contribution of usability challenges associated with the electronic medication administration record (eMAR) to medication errors.

METHODS

Free-text descriptions of 849 medication-related PSEs selected from 2.3 million reports were analyzed. Coders identified the specific health IT components, usability challenge categories, and nuanced usability themes that contributed to each PSE. Thematic analysis was conducted to refine categorizations and identify emerging themes. Final analysis was limited to PSEs involving a contribution from eMAR, either as the point of origin or as a downstream contributor to error.

RESULTS

eMAR contributed to 473 PSEs. eMAR was the point of origin for 84 (17.8% of 473) PSEs. Usability challenge categories included Workflow support (n = 52, 11.0%) and Display/Visual clutter (n = 30, 6.3%). eMAR contributed downstream from the point of origin in 389 (82.2% of 473) PSEs, with errors stemming primarily from Pharmacy IT and computerized provider order entry (CPOE). Prominent secondary eMAR-associated usability challenges included Display/Visual clutter (n = 327, 69.1%) and Alerting (n = 32, 6.8%).

CONCLUSION

This study identified several eMAR usability challenges, through the analysis of PSEs, that contribute to medication errors. Findings highlight the critical need for improving the eMAR user interface. Improved interface design, better vendor usability testing, eMAR-focused certification testing, consideration of work system factors, and eMAR-focused usability and safety testing by health care facilities can improve eMAR technology and patient safety.

Behavioral signs of an unintended error in nursing information sharing with electronic clinical pathways: a mixed research approach

Electronic clinical pathways (ECPs) strongly encourage the standardization of medical treatment and the sharing of information among medical staff. The goal of this study was to determine the influence of ECPs on information sharing among nurses in a university hospital. Four experienced nurses, selected based on ECP composing and operation experience, were recruited from the department with the most frequent users in the first-round interview, 132 nurses' questionnaire answers were analyzed, and eight nurses participated in the second-round interview. This study conducted a mixed-method (interview-questionnaire-interview) investigation to extract the behavioral signs of unintended errors in information sharing after the ethical approval was obtained. On the basis of ANOVA and t-test for the questionnaire and constant comparison for interview, this study found that the greater extent of user dependency on convenient ECPs in the frequent-use group led to mistakes under hectic conditions. This study also found evidence of poor management of ECPs when problems occurred. The immature design of ECPs provoked inappropriate behaviors among nurses even though they brought about some benefits such as mitigation of the burden of daily recording tasks. The findings empirically showed the ECP user's behavioral changes regarding the technology-induced error.

Dose Verification Errors in Hospitals: Literature Review of the eMAR-based Systems Used by Nurses

BACKGROUND

The effectiveness of the dose verification features of the electronic medication administration record (eMAR) and complementary systems in the hospital setting is not well understood.

PURPOSE

The authors completed a narrative synthesis of literature findings on the effectiveness of eMAR-based systems in the hospital setting.

METHODS

A literature review was carried out across 5 bibliographic databases to evaluate the safety features of current eMAR-based systems in preventing dosing errors and design issues that impede their usability.

RESULTS

While eMAR-based systems are beneficial to reducing order and drug cross-checking errors, safe dose verification features are sporadically available for targeted tasks. Overall, the eMAR had little impact on preventing low to moderate dosing errors. Dosing errors may occur because of error-prone activities that result from system design and work process issues during medication administration.

Interdisciplinary systematic review: does alignment between system and design shape adoption and use of barcode medication administration technology?

BACKGROUND

In order to reduce safety risks associated with medication administrations, technologies such as barcode medication administration (BCMA) are increasingly used. Examining how human factors influence adoption and usability of this technology can potentially highlight areas for improvement in design and implementation.

OBJECTIVE

To describe how human factors related determinants for BCMA have been researched and reported by healthcare and human-computer interaction disciplines.

DATA SOURCES

The Cumulative Index of Nursing, and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar.

STUDY ELIGIBILITY CRITERIA

Primary research published from April 2000 to April 2020, search terms developed to identity different disciplinary research perspectives that examined BCMA use, used a human factors lens and were published in English.

SYNTHESIS METHODS

Computerised systematic searches were conducted in four databases. Eligible papers were systematically analysed for themes. Themes were discussed with a second reviewer and supervisors to ensure they were representative of content.

RESULTS

Of 3707 papers screened, 11 were included. Studies did not fit neatly into a clinical or human-computer interaction perspective but instead uncovered a range of overlapping narratives, demonstrating consensus on the key themes despite differing research approaches. Prevalent themes were misaligned design and workflow, adaptation and workarounds, mediating factors, safety, users' perceptions and design and usability. Inadequate design frequently led to workarounds, which jeopardised safety. Reported mediating factors included clarity of user needs, pre/post implementation evaluations, analysis of existing workarounds and appropriate technology, infrastructure and staffing.

LIMITATIONS

Most studies were relatively small and qualitative, making it difficult to generalise findings.

CONCLUSION

Evaluating interdisciplinary perspectives including human factors approaches identified similar and complementary enablers and barriers to successful technology use. Often, mediating factors were developed to compensate for unsuitable design; a collaborative approach between system designer and end users is necessary for BCMA to achieve its true safety potential.

Medical Device Workarounds in Providing Care for Children With Medical Complexity in the Home

OBJECTIVES

Children with medical complexity (CMC) are commonly assisted by medical devices, which family caregivers are responsible for managing and troubleshooting in the home. Optimizing device use by maximizing the benefits and minimizing the complications is a critical goal for CMC but is relatively unexplored. In this study, we sought to identify and describe workarounds families have developed to optimize medical device use for their needs.

METHODS

We conducted 30 contextual inquiry interviews with families of CMC in homes. Interviews were recorded, transcribed, and analyzed for barriers and workarounds specific to medical device usage through a directed content analysis. We used observation notes and photographs to confirm and elaborate on interview findings.

RESULTS

We identified 4 barriers to using medical devices in the home: (1) the quantity and type of devices allotted do not meet family needs, (2) the device is not designed to be used in locations families require, (3) device use is physically or organizationally disruptive to the home, and (4) the device is not designed to fit the user. We also identified 11 categories of workarounds to the barriers.

CONCLUSIONS

Families face many barriers in using medical devices to care for CMC. Our findings offer rich narrative and photographic data revealing the ways in which caregivers work around these barriers. Future researchers should explore the downstream effects of these ubiquitous, necessary workarounds on CMC outcomes toward developing interventions that optimize device use for families.

Implementation of distributed automated medication dispensing units in a new hospital: Nursing and pharmacy experience

AIMS AND OBJECTIVES

To explore the structures, processes and outcomes involved in an Automated Medication Dispensing system implementation and its impact on patient safety.

BACKGROUND

Increasing digitalisation of medication prescribing, dispensing, administration and stock management has occurred over the past two decades. While automated medication dispensing units aim to provide safe, high-quality, patient-centred care, the implementation may result in unintended consequences leading to suboptimal outcomes.

DESIGN

This study uses a qualitative approach guided by Donabedian's structure, process and outcome framework.

METHODS

Twenty-six registered nurses and pharmacy assistant staff, from clinical areas equipped with automated medication dispensing cabinets, participated in semi-structured interviews. In-depth, thematic analysis explored the structures and processes. Together with interview data, content analysis of text data generated by internal risk management and critical incident reporting systems was undertaken to evaluate outcomes. Findings were considered in light of the Interactive Sociotechnical Analysis approach to health information technology. The COREQ checklist was used in preparation of this article.

RESULTS

Pharmacy assistants reported better satisfaction with the system at implementation than nurses. Training provided for nurses and their involvement in system implementation was reported as insufficient; however, nurses' use of and satisfaction with the system improved over time. A recursive relationship between the changes imposed by the system and nurses' creative problem solving (workarounds) used to manage these changes, impacted work productivity for nurses and safety for patients.

CONCLUSIONS

The individualised nature of "workarounds" employed offered both risks and opportunities which require further identification, investigation and management.

RELEVANCE TO CLINICAL PRACTICE

Nurses are the majority of the health workforce. Digitalisation of traditionally paper-based activities in health care, impacting nursing work, requires similar strategies to any practice change.

Remembering Ben-Tzion Karsh's scholarship, impact, and legacy

Dr. Ben-Tzion (Bentzi) Karsh was a mentor, collaborator, colleague, and friend who profoundly impacted the fields of human factors and ergonomics (HFE), medical informatics, patient safety, and primary care, among others. In this paper we honor his contributions by reflecting on his scholarship, impact, and legacy in three ways: first, through an updated simplified bibliometric analysis in 2020, highlighting the breadth of his scholarly impact from the perspective of the number and types of communities and collaborators with which and whom he engaged; second, through targeted reflections on the history and impact of Dr. Karsh's most cited works, commenting on the particular ways they impacted our academic community; and lastly, through quotes from collaborators and mentees, illustrating Dr. Karsh's long-lasting impact on his contemporaries and students.

An Evaluation of the Impact of Barcode Patient and Medication Scanning on Nursing Workflow at a UK Teaching Hospital

Barcode medication administration (BCMA) is advocated as a technology that reduces medication errors relating to incorrect patient identity, drug or dose. Little is known, however, about the impact it has on nursing workflow. Our aim was to investigate the impact of BCMA on nursing activity and workflow. A comparative study was conducted on two similar surgical wards within an acute UK hospital. We observed nurses during drug rounds on a non-BCMA ward and a BCMA ward. Data were collected on drug round duration, timeliness of medication administration, patient identification, medication verification and general workflow patterns. BCMA appears not to alter drug round duration, although it may reduce the administration time per dose. Workflow was more streamlined, with less use of the medicines room. The rate of patient identification increased from 74% (of 47) patients to 100% (of 43), with 95% of 255 scannable medication doses verified using the system. This study suggests that BCMA does not affect drug round duration; further research is required to determine the impact it has on timeliness of medication administration. There was reduced variability in the medication administration workflow of nurses, along with an increased patient identification rate and high medication scan rate, representing potential benefits to patient safety.

Nurse workarounds in the electronic health record: An integrative review

OBJECTIVE

The study sought to synthesize published literature on direct care nurses' use of workarounds related to the electronic health record.

MATERIALS AND METHODS

We conducted an integrative review of qualitative and quantitative peer-reviewed research through a structured search of Academic Search Complete, EBSCO Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Engineering Village, Ovid Medline, Scopus, and Web of Science. We systematically applied exclusion rules at the title, abstract, and full article stages and extracted and synthesized their research methods, workaround classifications, and probable causes from articles meeting inclusion criteria.

RESULTS

Our search yielded 5221 results. After removing duplicates and applying rules, 33 results met inclusion criteria. A total of 22 articles used qualitative approaches, 10 used mixed methods, and 1 used quantitative methods. While researchers may classify workarounds differently, they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Each study identified probable causes, which included technology, task, organizational, patient, environmental, and usability factors.

CONCLUSIONS

Extensive study of nurse workarounds in acute settings highlights the gap in ambulatory care research. Despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team. The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system. Research is needed to explore the gaps in our understanding of and identify strategies to reduce workaround behaviors.

Alert Types and Frequencies During Bar Code-Assisted Medication Administration: A Systematic Review

BACKGROUND

Existing literature explores the effectiveness of bar code-assisted medication administration (BCMA) on the reduction of medication administration error as well as on nurse workarounds during BCMA. However, there is no review that comprehensively explores types and frequencies of alerts generated by nurses during BCMA.

PURPOSE

The purpose was to describe alert generation type and frequency during BCMA.

METHODS

A systematic review of the literature using PRISMA guidelines was conducted using CINAHL, PubMed, EMBASE, and Ovid Medline databases.

RESULTS

After screening for inclusion and exclusion criteria, a total of 8 articles were identified and included in the review. Alert types included patient mismatch, wrong medication, and wrong dose, though other alert types were also reported. The frequency of alert generation varied across studies, from 0.18% to 42%, and not all alerts were clinically meaningful.

CONCLUSIONS

This systematic review synthesized literature related to alert type and frequency during BCMA. However, further studies are needed to better describe alert generation patterns as well as factors that influence alert generation.

The Effects of Technological Developments on Work and Their Implications for Continuous Vocational Education and Training: A Systematic Review

Technology is changing the way organizations and their employees need to accomplish their work. Empirical evidence on this topic is scarce. The aim of this study is to provide an overview of the effects of technological developments on work characteristics and to derive the implications for work demands and continuous vocational education and training (CVET). The following research questions are answered: What are the effects of new technologies on work characteristics? What are the implications thereof for continuous vocational education and training? Technologies, defined as digital, electrical or mechanical tools that affect the accomplishment of work tasks, are considered in various disciplines, such as sociology or psychology. A theoretical framework based on theories from these disciplines (e.g., upskilling, task-based approach) was developed and statements on the relationships between technology and work characteristics, such as complexity, autonomy, or meaningfulness, were derived. A systematic literature review was conducted by searching databases from the fields of psychology, sociology, economics and educational science. Twenty-one studies met the inclusion criteria. Empirical evidence was extracted and its implications for work demands and CVET were derived by using a model that illustrates the components of learning environments. Evidence indicates an increase in complexity and mental work, especially while working with automated systems and robots. Manual work is reported to decrease on many occasions. Workload and workflow interruptions increase simultaneously with autonomy, especially with regard to digital communication devices. Role expectations and opportunities for development depend on how the profession and the technology relate to each other, especially when working with automated systems. The implications for the work demands necessary to deal with changes in work characteristics include knowledge about technology, openness toward change and technology, skills for self- and time management and for further professional and career development. Implications for the design of formal learning environments (i.e., the content, method, assessment, and guidance) include that the work demands mentioned must be part of the content of the trainings, the teachers/trainers must be equipped to promote those work demands, and that instruction models used for the learning environments must be flexible in their application.

Factors associated with workarounds in barcode-assisted medication administration in hospitals

Aims and objectives

To identify that workarounds (defined as “informal temporary practices for handling exceptions to normal procedures or workflow”) by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode‐assisted Medication Administration in hospitals.

Background

Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology‐based interventions as Barcode‐assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better‐designed software and processes which fit the nurse workflow.

Design

We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients.

Methods

Data were collected from 2014–2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data.

Results

We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.–06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05–2.45) and 06 p.m.–10 p.m. (adjusted OR: 3.60, 95% CI: 2.11–6.14) versus the morning shift 06 a.m.–10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51–4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2–3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31–3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05–1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification‐coded medication “other” (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05–2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient–nurse ratio ≥6–1 (adjusted OR: 5.61, 95% CI: 2.9–10.83) versus ≤5–1.

Conclusions

We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode‐assisted Medication Administration.

Relevance to clinical practice

Nurses administering medication in hospitals using Barcode‐assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient–nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.

Self-Directed and Lifelong Learning: A Framework for Improving Nursing Students’ Learning Skills in the Clinical Context

Self-directed lifelong learning is an important competency for nursing students to meet their professional development, yet it can be challenging for some students to acquire self-directed learning skills in a clinical context. A framework based on Hiemstra and Brockett’s “Person, Process, Context” model was developed to promote nurses' self-directed lifelong learning. The implication stems from our expectation that the framework can accelerate the development of interpersonal and intellectual skills valuable to a nursing student’s lifelong learning process.

Heuristics for designing user-centric drug products: Lessons learned from Human Factors and Ergonomics

Even the most effective drug product may be used improperly and thus ultimately prove ineffective if it does not meet the perceptual, motor and cognitive capacities of its target users. Currently, no comprehensive guideline for systematically designing user‐centric drug products that would help prevent such limitations exists. We have compiled a list of approximate but nonetheless useful strategies—heuristics—for implementing a user‐centric design of drug products and drug product portfolios. First, we present a general heuristic for user‐centric design based on the framework of Human Factors and Ergonomics (HF/E). Then we demonstrate how to implement this general heuristic for older drug users (i.e., patients and caregivers aged 65 years and older) and with respect to three specific challenges (use‐cases) of medication management: (A) knowing what drug product to take/administer, (B) knowing how and when to take/administer it, and (C) actually taking/administering it. The presented heuristics can be applied prospectively to include existing knowledge about user‐centric design at every step during drug discovery, pharmaceutical drug development, and pre‐clinical and clinical trials. After a product has been released to the market, the heuristics may guide a retrospective analysis of medication errors and barriers to product usage as a basis for iteratively optimizing both the drug product and its portfolio over their life cycle.

Technology barriers and strategies in coordinating care for chronically ill patients

Care managers who coordinate care for chronically ill patients in hospitals and outpatient settings use multiple health information technologies for accessing, processing, documenting, and communicating patient-related information. Using a combination of 41 interviews and observations of 15 care managers, we identified a range of technology-related barriers experienced by care managers (total of 163 occurrences). The barriers are related to (lack of) access to information, inadequate information, limited usefulness and usability of the technologies, challenges associated with using multiple health IT, and technical problems. In 43% of the occurrences, care managers describe strategies to deal with the technology barriers; these fit in three categories: nothing/delay (9 occurrences), work-arounds (32 occurrences), and direct action at the individual, team, and organization levels (29 occurrences). Our data show the adaptive capacity of care managers who develop various strategies to deal with technology barriers and are, therefore, able to care for chronically ill patients. This information can be used as input to work system redesigns.

The use of robots and other automated devices in nurses' work: An integrative review

BACKGROUND

Future nursing shortages and advanced technological developments mean that robots and automated devices could play a valuable role in nursing, but little has been published on their use, and outcomes, to date.

AIM

This integrative review identified how robots are currently used in nursing and the outcomes of those initiatives.

DESIGN

This study used integrative review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

We searched the CINAHL, PubMed, Web of Science, and Scopus databases for peer-reviewed papers published in English from January 2010 to August 2018.

REVIEW METHODS

The five-stage review process by Whittemore and Knafl was used.

RESULTS

The 25 included papers showed that robots and automated devices were mainly used in nursing to deliver medication, monitor patients, and provide nursing treatments. The outcomes were evaluated in relation to patient safety, working time and workload, usability, and the end users' satisfaction. In addition, the costs, care outcomes, nurses' behaviour, and changes in working procedures were considered.

CONCLUSIONS

Robots and automated devices have the potential to develop nurses' work, but more research and critical evaluations are needed to find the most suitable devices and focus on the functions that will provide the best outcomes for nurses' work.

HOW BAR CODED MEDICATION ADMINISTRATION TECHNOLOGY AFFECTS THE NURSE-PATIENT RELATIONSHIPS: AN ETHNOGRAPHIC STUDY

OBJECTIVES

This study aims to assess how care is mediated through technology by analyzing the interaction between nurses, patients, and a Bar Coded Medication Administration (BCMA) system. The objective is to explore how patients experience care through medication technology, with the main focus of our observations and interviews on nurses rather than patients.

METHODS

A qualitative ethnographic study was conducted in an orthopedic ward of a Dutch general hospital.

RESULTS

After analyses, the following two themes were discerned: (i) the use of bar code medication technology organizes double institutionalization, and (ii) nurses frequently need to work around the BCMA, as the system is not always supportive of patient needs.

CONCLUSIONS

The results of this study indicate that BCMA is not merely a neutral tool, but an active component within the nurse-patient relationship, as it influences medication administration and profoundly affects patient participation in the care process.

Nurses' knowledge and deliberations crucial to Barcoded Medication Administration technology in a Dutch hospital: Discovering nurses' agency inside ruling

This article shows how Barcoded Medication Administration technology institutionally organizes and rules the daily actions of nurses. Although it is widely assumed that Barcoded Medication Administration technology improves quality and safety by reducing the risk of human error, little research has been done on how this technology alters the work of nurses. Drawing on empirical and conceptual strategies of analysis, this qualitative study used certain tools of institutional ethnography to provide a view of how nurses negotiate Barcoded Medication Administration technology. The approach also uses elements from practice theory in order to discern how technology operates as a player on the field instead of being viewed as a 'mere' tool. A literature review preceded participant observation, whereby 17 nurses were followed and data on an orthopaedic ward were collected over a period of 9 months in 2011 and 2012. Barcoded Medication Administration technology relies on nurses' knowledge to mediate between the embedded logics of its design and the unpredictable needs of patients. Nurses negotiate their own professional logic of care in the form of moment-to-moment deliberations which subvert the ruling frame of the barcoded system and its objectified model of patient safety. The logic of Barcoded Medication Administration technology differs from the logic of nursing care, as this technology presumes medication distribution to be linear, even though nurses follow another line of actor-bound safety practices that we characterize as 'deliberations'.

Workarounds to Intended Use of Health Information Technology: A Narrative Review of the Human Factors Engineering Literature

Objective To integrate and synthesize insights from recent studies of workarounds to the intended use of health information technology (HIT) by health care professionals. Background Systems are safest when the documentation of how work is done in policies and procedures closely matches what people actually do when they are working. Proactively identifying and managing workarounds to the intended use of technology, including deviations from expected workflows, can improve system safety. Method A narrative review of studies of workarounds with HIT was conducted to identify themes in the literature. Results Three themes were identified: (1) Users circumvented new additional steps in the workflow when using HIT, (2) interdisciplinary team members communicated via HIT in text fields that were intended for other purposes, and (3) locally developed paper-based and manual whiteboard systems were used instead of HIT to support situation awareness of individuals and groups; an example of a locally developed system was handwritten notes about a patient on a piece of paper folded up and carried in a nurse's pocket. Conclusion Workarounds were employed to avoid changes to workflow, enable interdisciplinary communication, coordinate activities, and have real-time portable access to summarized and synthesized information. Application Implications for practice include providing summary overview displays, explicitly supporting role-based communication and coordination through HIT, and reducing the risk to reputation due to electronic monitoring of individual performance.

Toward a process-level view of distributed healthcare tasks: Medication management as a case study

We aim to highlight the importance of using a process-level view in analyzing distributed healthcare tasks through a case study analysis of medication management (MM). MM during older adults' hospital-to-skilled-home-healthcare (SHHC) transitions is a healthcare process with tasks distributed across people, organizations, and time. MM has typically been studied at the task level, but a process-level is needed to fully understand and improve MM during transitions. A process-level view allows for a broader investigation of how tasks are distributed throughout the work system through an investigation of interactions and the resultant emergent properties. We studied MM during older adults' hospital-to-SHHC transitions through interviews and observations with 60 older adults, their 33 caregivers, and 79 SHHC providers at 5 sites associated with 3 SHHC agencies. Study findings identified key cross-system characteristics not observable at the task-level: (1) identification of emergent properties (e.g., role ambiguity, loosely-coupled teams performing MM) and associated barriers; and (2) examination of barrier propagation across system boundaries. Findings highlight the importance of a process-level view of healthcare delivery occurring across system boundaries.

Human factors in mental healthcare: A work system analysis of a community-based program for older adults with depression and dementia

Mental healthcare is a critical but largely unexplored application domain for human factors/ergonomics. This paper reports on a work system evaluation of a home-based dementia and depression care program for older adults, the Aging Brain Care program. The Workflow Elements Model was used to guide data collection and analysis of 59 h of observation, supplemented by key informant input. We identified four actors, 37 artifacts across seven types, ten action categories, and ten outcomes including improved health and safety. Five themes emerged regarding barriers and facilitators to care delivery in the program: the centrality of relationship building; the use of adaptive workarounds; performance of duplicate work; travel and scheduling challenges; and communication-related factors. Findings offer new insight into how mental healthcare services are delivered in a community-based program and key work-related factors shaping program outcomes.

Medication management strategies used by older adults with heart failure: A systems-based analysis

BACKGROUND

Older adults with heart failure use strategies to cope with the constraining barriers impeding medication management. Strategies are behavioral adaptations that allow goal achievement despite these constraining conditions. When strategies do not exist, are ineffective or maladaptive, medication performance and health outcomes are at risk. While constraints to medication adherence are described in literature, strategies used by patients to manage medications are less well-described or understood.

AIM

Guided by cognitive engineering concepts, the aim of this study was to describe and analyze the strategies used by older adults with heart failure to achieve their medication management goals.

METHODS

This mixed methods study employed an empirical strategies analysis method to elicit medication management strategies used by older adults with heart failure. Observation and interview data collected from 61 older adults with heart failure and 31 caregivers were analyzed using qualitative content analysis to derive categories, patterns and themes within and across cases.

RESULTS

Data derived thematic sub-categories described planned and ad hoc methods of strategic adaptations. Stable strategies proactively adjusted the medication management process, environment, or the patients themselves. Patients applied situational strategies (planned or ad hoc) to irregular or unexpected situations. Medication non-adherence was a strategy employed when life goals conflicted with medication adherence. The health system was a source of constraints without providing commensurate strategies.

CONCLUSIONS

Patients strived to control their medication system and achieve goals using adaptive strategies. Future patient self-mangement research can benefit from methods and theories used to study professional work, such as strategies analysis.

Tinker, tailor, deliberate. An ethnographic inquiry into the institutionalized practice of bar-coded medication administration technology by nurses

AIM

Explore the practice of nurses working with bar-coded medication administration technology, to gain insight in the impact it has on their work.

BACKGROUND

The widespread presumption of using Barcoded Medication Administration Technology (BCMA) is that it will effectively reduce the number of errors in the dispensing of medication to patients. However, it remains unclear whether this is the case in actual practice.

METHOD

Two distinct but overlapping research methodologies of Institutional Ethnography and Praxeology were combined as a means to uncover the highly complex practice of BCMA by nurses.

RESULTS

The implementation of BCMA creates a series of problems leading to nurses constantly tinkering with the technology. At the same time they are continuously deliberating the best ways of tailoring the BCMA to each of their patients.

CONCLUSION

Although working with BCMA is often misconstrued as being mindless and automatic, conforming to the technology, this tinkering with BCMA in fact always entails thorough deliberation by nurses.

Methods for Addressing Technology-induced Errors: The Current State

OBJECTIVES

The objectives of this paper are to review and discuss the methods that are being used internationally to report on, mitigate, and eliminate technology-induced errors.

METHODS

The IMIA Working Group for Health Informatics for Patient Safety worked together to review and synthesize some of the main methods and approaches associated with technology- induced error reporting, reduction, and mitigation. The work involved a review of the evidence-based literature as well as guideline publications specific to health informatics.

RESULTS

The paper presents a rich overview of current approaches, issues, and methods associated with: (1) safe HIT design, (2) safe HIT implementation, (3) reporting on technology-induced errors, (4) technology-induced error analysis, and (5) health information technology (HIT) risk management. The work is based on research from around the world.

CONCLUSIONS

Internationally, researchers have been developing methods that can be used to identify, report on, mitigate, and eliminate technology-induced errors. Although there remain issues and challenges associated with the methodologies, they have been shown to improve the quality and safety of HIT. Since the first publications documenting technology-induced errors in healthcare in 2005, we have seen in a short 10 years researchers develop ways of identifying and addressing these types of errors. We have also seen organizations begin to use these approaches. Knowledge has been translated into practice in a short ten years whereas the norm for other research areas is of 20 years.

Understanding Unintended Consequences and Health Information Technology:. Contribution from the IMIA Organizational and Social Issues Working Group

OBJECTIVE

No framework exists to identify and study unintended consequences (UICs) with a focus on organizational and social issues (OSIs). To address this shortcoming, we conducted a literature review to develop a framework for considering UICs and health information technology (HIT) from the perspective of OSIs.

METHODS

A literature review was conducted for the period 2000- 2015 using the search terms "unintended consequences" and "health information technology". 67 papers were screened, of which 18 met inclusion criteria. Data extraction was focused on the types of technologies studied, types of UICs identified, and methods of data collection and analysis used. A thematic analysis was used to identify themes related to UICs.

RESULTS

We identified two overarching themes. One was the definition and terminology of how people classify and discuss UICs. Second was OSIs and UICs. For the OSI theme, we also identified four sub-themes: process change and evolution, individual-collaborative interchange, context of use, and approaches to model, study, and understand UICs.

CONCLUSIONS

While there is a wide body of research on UICs, there is a lack of overall consensus on how they should be classified and reported, limiting our ability to understand the implications of UICs and how to manage them. More mixed-methods research and better proactive identification of UICs remain priorities. Our findings and framework of OSI considerations for studying UICs and HIT extend existing work on HIT and UICs by focusing on organizational and social issues.

Provider Use of a Novel EHR display in the Pediatric Intensive Care Unit. Large Customizable Interactive Monitor (LCIM)

OBJECTIVES

The purpose of this study was to explore providers' perspectives on the use of a novel technology, "Large Customizable Interactive Monitor" (LCIM), a novel application of the electronic health record system implemented in a Pediatric Intensive Care Unit.

METHODS

We employed a qualitative approach to collect and analyze data from pediatric intensive care physicians, pediatric nurse practitioners, and acute care specialists. Using semi-structured interviews, we collected data from January to April, 2015. The research team analyzed the transcripts using an iterative coding method to identify common themes.

RESULTS

Study results highlight contextual data on providers' use routines of the LCIM. Findings from thirty six interviews were classified into three groups: 1) providers' familiarity with the LCIM; 2) providers' use routines (i.e. when and how they use it); and 3) reasons why they use or do not use it.

CONCLUSION

It is important to conduct baseline studies of the use of novel technologies. The importance of training and orientation affects the adoption and use patterns of this new technology. This study is notable for being the first to investigate a LCIM system, a next generation system implemented in the pediatric critical care setting. Our study revealed this next generation HIT might have great potential for family-centered rounds, team education during rounds, and family education/engagement in their child's health in the patient room. This study also highlights the effect of training and orientation on the adoption patterns of new technology.

Analysis of the technology acceptance model in examining hospital nurses' behavioral intentions toward the use of bar code medication administration

Serious medication errors continue to exist in hospitals, even though there is technology that could potentially eliminate them such as bar code medication administration. Little is known about the degree to which the culture of patient safety is associated with behavioral intention to use bar code medication administration. Based on the Technology Acceptance Model, this study evaluated the relationships among patient safety culture and perceived usefulness and perceived ease of use, and behavioral intention to use bar code medication administration technology among nurses in hospitals. Cross-sectional surveys with a convenience sample of 163 nurses using bar code medication administration were conducted. Feedback and communication about errors had a positive impact in predicting perceived usefulness (β=.26, P<.01) and perceived ease of use (β=.22, P<.05). In a multiple regression model predicting for behavioral intention, age had a negative impact (β=-.17, P<.05); however, teamwork within hospital units (β=.20, P<.05) and perceived usefulness (β=.35, P<.01) both had a positive impact on behavioral intention. The overall bar code medication administration behavioral intention model explained 24% (P<.001) of the variance. Identified factors influencing bar code medication administration behavioral intention can help inform hospitals to develop tailored interventions for RNs to reduce medication administration errors and increase patient safety by using this technology.

Safety challenges of medical equipment in nurse anaesthetist training in Haiti

Safety challenges related to the use of medical equipment were investigated during the training of nurse anaesthetists in Haiti, using a systems approach to Human Factors and Ergonomics (HFE). The Observable Performance Obstacles tool, based on the Systems Engineering Initiative for Patient Safety (SEIPS) model, was used in combination with exploratory observations during 13 surgical procedures, to identify performance obstacles created by the systemic interrelationships of medical equipment. The identification of performance obstacles is an effective way to study the accumulation of latent factors and risk hazards, and understand its implications in practice and behaviour of healthcare practitioners. In total, 123 performance obstacles were identified, of which the majority was related to environmental and organizational aspects. These findings show how the performance of nurse anaesthetists and their relation to medical equipment is continuously affected by more than user-related aspects. The contribution of systemic performance obstacles and coping strategies to enrich system design interventions and improve healthcare system is highlighted. In addition, methodological challenges of HFE research in low-resource settings related to professional culture and habits, and the potential of community ergonomics as a problem-managing approach are described.

Is technology the best medicine? Three practice theoretical perspectives on medication administration technologies in nursing

Even though it is often presumed that the use of technology like medication administration technology is both safer and more effective, the importance of nurses' know-how is not to be underestimated. In this article, we accordingly try to argue that nurses' labor, including their different forms of knowledge, must play a crucial role in the development, implementation and use of medication administration technology. Using three different theoretical perspectives ('heuristic lenses') and integrating this with our own ethnographic research, we will explore how nursing practices change through the use of medication technology. Ultimately, we will argue that ignoring (institutional) complexity and the various types of important knowledge that nurses have, will seriously complicate the implementation of medication administration technology.

The patient work system: an analysis of self-care performance barriers among elderly heart failure patients and their informal caregivers

Human factors and ergonomics approaches have been successfully applied to study and improve the work performance of healthcare professionals. However, there has been relatively little work in "patient-engaged human factors," or the application of human factors to the health-related work of patients and other nonprofessionals. This study applied a foundational human factors tool, the systems model, to investigate the barriers to self-care performance among chronically ill elderly patients and their informal (family) caregivers. A Patient Work System model was developed to guide the collection and analysis of interviews, surveys, and observations of patients with heart failure (n = 30) and their informal caregivers (n = 14). Iterative analyses revealed the nature and prevalence of self-care barriers across components of the Patient Work System. Person-related barriers were common and stemmed from patients' biomedical conditions, limitations, knowledge deficits, preferences, and perceptions as well as the characteristics of informal caregivers and healthcare professionals. Task barriers were also highly prevalent and included task difficulty, timing, complexity, ambiguity, conflict, and undesirable consequences. Tool barriers were related to both availability and access of tools and technologies and their design, usability, and impact. Context barriers were found across three domains-physical-spatial, social-cultural, and organizational-and multiple "spaces" such as "at home," "on the go," and "in the community." Barriers often stemmed not from single factors but from the interaction of several work system components. Study findings suggest the need to further explore multiple actors, contexts, and interactions in the patient work system during research and intervention design, as well as the need to develop new models and measures for studying patient and family work.

The Threat-Strategy Interview

Operators in dynamic work environments use strategies to manage threats in order to achieve task goals. We introduce a structured interview method, the Threat-Strategy Interview (TSI), and an accompanying qualitative analysis to induce operator-level threats, strategies, and the cues that give rise to them. The TSI can be used to elicit knowledge from operators who are on the front line of managing threats to provide an understanding of strategic thinking, which in turn can be applied toward a variety of problems.

Evaluation of a BCMA's Electronic Medication Administration Record

Barcode medication administration (BCMA) systems can reduce medication errors, but sociotechnical issues are quite common. Although crucial to nurses' work, few usability evaluations are available for electronic medication administration record (eMARs) screens. The purpose of this research was to identify current usability problems in the Veterans Administration's (VA) eMAR/BCMA system and explore how these might affect nurses' situation awareness (SA). Three expert evaluators used 10 tasks/elements, heuristic evaluation techniques, and explored potential impacts using a SA perspective. The results yielded 99 usability problems categorized into 440 heuristic violations with the largest volume in the category of Match With the Real World. Fifteen usability issues were rated as catastrophic with the Administer/Chart medications task having the most. Situational awareness was affected at all levels, especially at Level 2, Comprehension. Usability problems point to important areas for improvement, because these issues have the potential to affect nurses' SA, "at a glance" information, nurse productivity, and patient safety.

Human factors and health information technology: current challenges and future directions

OBJECTIVES

Recent federal mandates and incentives have spurred the rapid growth, development and adoption of health information technology (HIT). While providing significant benefits for better data integration, organization, and availability, recent reports have raised questions regarding their potential to cause medication errors, decreased clinician performance, and lowered efficiency. The goal of this survey article is to (a) examine the theoretical and foundational models of human factors and ergonomics (HFE) that are being advocated for achieving patient safety and quality, and their use in the evaluation of healthcare systems; (b) and the potential for macroergonomic HFE approaches within the context of current research in biomedical informatics.

METHODS

We reviewed literature (2007-2013) on the use of HFE approaches in healthcare settings, from databases such as Pubmed, CINAHL, and Cochran.

RESULTS

Based on the review, we discuss the systems-oriented models, their use in the evaluation of HIT, and examples of their use in the evaluation of EHR systems, clinical workflow processes, and medication errors. We also discuss the opportunities for better integrating HFE methods within biomedical informatics research and its potential advantages.

CONCLUSIONS

The use of HFE methods is still in its infancy - better integration of HFE within the design lifecycle, and quality improvement efforts can further the ability of informatics researchers to address the key concerns regarding the complexity in clinical settings and develop HIT solutions that are designed within the social fabric of the considered setting.

Human factors systems approach to healthcare quality and patient safety

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients

Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, 'SEIPS 2.0'. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at 'a moment in time'. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

A typology of electronic health record workarounds in small-to-medium size primary care practices

OBJECTIVE

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features.

MATERIALS AND METHODS

Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff.

RESULTS

We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds.

CONCLUSIONS

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Using a sociotechnical framework to understand adaptations in health IT implementation

PURPOSE

When barcode medication administration (BCMA) is implemented nurses are required to integrate not only a new set of procedures or artifacts into everyday work, but also an orientation to medication safety itself that is sometimes at odds with their own. This paper describes how the nurses' orientation (the Practice Frame) can collide with the orientation that is represented by the technology and its implementation (the System Frame), resulting in adaptations at the individual and organization levels.

METHODS

The paper draws on two qualitative research studies that examined the implementation of BCMA in inpatient settings using observation and ethnographic fieldwork, content analysis of email communications, and interviews with healthcare professionals.

RESULTS

Two frames of reference are described: the System Frame and the Practice Frame. We found collisions of these frames that prompted adaptations at the individual and organization levels. The System Frame was less integrated and flexible than the Practice Frame, less able to account for all of the dimensions of everyday patient care to which medication administration is tied.

CONCLUSION

Collisions in frames during implementation of new technology result in adaptations at the individual and organization level that can have a variety of effects. We found adaptations to be a means of evolving both the work routines and the technology. Understanding the frames of clinical workers when new technology is being designed and implemented can inform changes to technology or organizational structure and policy that can preclude unproductive or unsafe adaptations.